“Integrated Medical Learning® allows participants to define the content and direction of sessions targeted at the most practical and important clinical and scientific questions of the day. Learners evaluate key evidence, interact with faculty, and define current and future practice.” CNS Website (To learn more about the IML program see previous Department of Neurological Surgery blog: Results from first IML: Aneurysm Coiling v. Clipping Still a Toss up)

Before the meeting, review articles on the latest developments in the surgical treatment of CM-1 were made accessible (pediatric review articles) to attendees. Surveys were also sent out to poll them in an effort to guide the presentations. The question they determined to address was “What extent of decompression is necessary in the surgical management of Chiari 1 Malformations (CM-1)?”

CM-1 is a congenital (present at birth) condition where bony malformation causes part of the brain to push down into the spinal canal. Sometimes this problem exists without any symptoms, in which case, most surgeons just leave it alone. Sometimes symptoms manifest when the person is well into adulthood. Symptoms can include headaches, stiffness or pain in the back of the neck, difficulty swallowing, and decreased strength or feeling in the arms and legs. Children with this problem may exhibit developmental delays. The treatment of CM-1 is surgical. The goal of which is to take pressure off of the spinal cord and brain by performing a decompression.

The area under pressure is decompressed by removing bone, often from the top of the spine and sometimes from the skull. Traditionally the membrane surrounding the spinal cord, the dura, is also opened up and a graft inserted to make more room for the spinal cord. There is debate among pediatric neurosurgeons as to whether the dura absolutely has to be opened, however.

The dura protects the brain and spinal cord and holds in its surrounding fluid. Deep within the brain a fluid is produced (cerebrospinal fluid) that circulates throughout the brain and spinal cord in a closed system. Pressure within this system is self regulating and because it is closed, the brain and spinal cord are protected from infection. Opening the dura is risky because it can offset the pressure system, let in germs, or introduce a leak. All of which can have serious consequences.

At this years CNS meeting, Dr. Feldstein presented an argument for decompression without dural opening. He presented a number of cases and research studies that support his stance. He conceded that in some rare cases it is absolutely necessary to do, however, for the most part, he and his fellow surgeons at the Pediatric Neurosurgery Center have found that the benefits of adding this procedure don’t always outweigh the risks and therefore do not automatically perform this part of the procedure.